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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200181
Report Date: 02/12/2024
Date Signed: 02/12/2024 02:36:33 PM

Document Has Been Signed on 02/12/2024 02:36 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:WOODHAVEN HOMEFACILITY NUMBER:
079200181
ADMINISTRATOR:MILAGROS N. QUEZONFACILITY TYPE:
735
ADDRESS:3319 WOODHAVEN LANETELEPHONE:
(925) 349-4225
CITY:CONCORDSTATE: CAZIP CODE:
94519
CAPACITY: 6CENSUS: 6DATE:
02/12/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Ma Navarro, StaffTIME COMPLETED:
03:00 PM
NARRATIVE
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While at the facility for Complaint number 15-AS-20240206134157 LPA J. Clancy-Czuleger observed that R1's file was not at the facility. LPA spoke with Licensee who confirmed that the file was not there and she could email it to the LPA and drop if off at the facility at a later time.

A civil penalty of $250.00 will be assessed on today’s date for repeated violation for section number 80070(a)- Client Records

Exit interview conducted with Licensee, a copy of this report provided along with an LIC421FC, and appeal rights.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE: DATE: 02/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/12/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/12/2024 02:36 PM - It Cannot Be Edited


Created By: Jill Clancy-Czuleger On 02/12/2024 at 02:12 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: WOODHAVEN HOME
FACILITY NUMBER: 079200181

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/12/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/14/2024
Section Cited
CCR
80070(a)

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(a) The licensee shall ensure that a separate, complete, and current record is maintained in the facility for each client.

This requirement is not met as evidenced by:
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The facility agrees to bring all resident records to the facility by POC date.

A $250.00 is assessed on this day
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Based on observation, interview and record review, the licensee did not comply with the section cited above by not keeping one resident record at the facility which poses/posed a potential health, safety or personal rights risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Harpreet Humpal
LICENSING EVALUATOR NAME:Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE:
DATE: 02/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/12/2024


LIC809 (FAS) - (06/04)
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